Here Comes The Rain Again.

As a UK native I am genetically programmed to talk about the weather, with
almost religious zeal. Like queuing in an orderly fashion and selling arms,
talking about the weather is what we in Britain do best. So, here goes.

It had been hot, very hot until the last few weeks. Slowly and without a lot
of warning, thick bubbling clouds began to appear on the edges of the
horizon. Huge columns of dark vapour hung in the air, menacing. On Monday it
was exceptionally hot, the heat building to a crescendo during lunchtime
until finally, at around four o'clock, mother nature flicked a switch and
unleashed a storm like I have never seen (and this from a bloke who has
spent many a summer in Ireland!). The rain fell by the gallon as fork
lightening and rumbling thunder rolled across the sky. The soil here has all
the absorbency of Lego and the water worked its way into natural divots
before wearing very large grooves in the ground.

Afterwards the village was complete mess. Most of the huts had been
constructed this year and had not been given the full rainy season acid
test. It was clear from the buckled roofs and walls that many had
spectacularly failed. The next few days were spent making hasty repairs.
Most of these repairs themselves needed repairs after a similarly vicious
squall on Thursday.

Anyway life at the clinic continued. We are currently preparing for my
'final' farewell tour; it has been a bit of a long goodbye. Six different
locations to visit and say 'cheery o' to so I'm starting to feel like one of
those ageing rock stars stuck on their nineteenth farewell tour.

The days spent in the clinic are ticking over nicely. We are waiting for the
road to dry up so we can transport timber and other logistical supplies to
try and patch up the clinic before heavy rain becomes and frequent rather
and infrequent visitor.

In many ways the clinical stuff is what keeps me going at times of
stagnation like this. We have had one child this week that was seen by me in
an outreach site. He was clearly gravely ill and it was the sort of case
that could have been diagnosed by the brownies. The child had meningitis,
pneumonia, malaria and tetanus. I hit him with every drug I had at my
disposal that I thought might do some good and told the mother to take him
to the base site. She didn't. I assumed the child had died on the way.

I returned to the base site with no news on where the child was. It was dark
and late at night when the clinics guard came to get me from my tent. The
rain was pouring down; all that my head torch could make out were the
thousands of dazzling, raindrops falling in front of me. 'Come, come' he
said. The rain moved up a few gears to the one labelled 'torrential'

We trudged through the mud along the path up to the clinic. And there,
crouched and soaked in the corner of the hut was the child and mother. There
had been a security problem along the road from the outreach clinic so she
had had to detour hugely.

The child was still alive, but there wasn't much in it. I called for back up
(the base doctor) and set about trying to sort out the patient. Again a
plethora of antibiotics and tetanus treatment was soon being sought. As I
hunted round the pitch-black medical store looking for boxes the doctor was
in the process of trying to resuscitate the child whose heart had just
stopped beating. The rain on the tin roof was so loud, despite being only a
few feet away I couldn't hear him calling for me.

Thankfully, miraculously, after a big slug of adrenaline the child returned
to healthy sinus rhythm but remained deeply unconscious. To say the
situation was bleak would be the understatement of the year, dire I think is
a more apt description. Four diseases all of which had the capability to
kill him, and he continued to fight them all throughout the days and nights
that followed. Ever day I left the clinic convinced the next time I'd see
him would be to break terrible news.

Yesterday he walked and giggled as we blew bubbles over his head. I wish
every case ended this way, but I guess if they did, then kids like this
wouldn't seem so special.

Five Things I Will Miss…. Five things I Won’t.

As time here draws rapidly to a conclusion I've been doing a lot of 'lasts'.
I've already said farewell to two outreach sites and in less than
forty-eight hours I will wave goodbye to one of the bases. Half of my job
effectively will be over. So I've turned a little introspective and thought
about what I will really miss and what I will, frankly, glad to see the back
of. So here, in an ever so, Sunday night Channel 4 kind of a way are my top
five of each. In no particular order, I'll end positive so start negative.

Things I won't miss….

1) Guns – This is a country supposed to be grabbing the opportunity of peace
with both hands, sadly the young men here seem much more willing to grab
their AK-47's and use the to lethal effect. We in the 'developed' world
should hang our heads in shame that we allowed such an enormous quantity of
armaments to flood this place, and have done nothing really to stem the
steady flow for decades. The results are clear everyday with the men women
and children I've seen killed and maimed, many by being shot accidentally.
It's such a waste of human life, and we should do so much more to stop it.
You can give me all that stuff about arms manufacture being really important
for the creation of jobs in the UK, but lining the walls of all our schools
with asbestos would create jobs, it's still not the right thing to do, is
it.

2) Villages with no access to water- I think this became a bit of a mantra
at some point around December I reckoned you'd probably all got bored so I
stopped writing about it. The problem hasn't gone away. In fact converting
our arms factories into water pump manufactures would kill two birds
...there's a plan

3) Statistics- can't stand maths, hate calculators. To be able to get
Microsoft Excel to do anything vaguely useful requires a brain the size of a
planet and a PhD in nerdology. Days of my life writing reports that no one
ever reads anyway. Dull dull dull dull dull dull dull.

4) Watching people die of preventable illnesses- It's pretty hard watching
people die at the best of times, it is almost unbearable when they die of
things that are preventable and curable in the west. In my opinion it is the
worst aspect of coming from a first world to a third world country. You know
what you could do if only you had the equipment, or drugs. I've lost count
of the number of times I've wished for a ventilator to fall from the sky, or
even just that parent's had been given the education to know when their
children were sick and bring them to the clinic sooner. And most of the time
it's really simple stuff.

5) The office politics- It's funny that if you ask most people what the
worst part of their job is they'll say, "oh, God the politics!" So, if this
is the case, why does it exist? I guess because we are all human, but it's
taken a super human effort to stay out of it, thankfully, by and large I've
managed it.

Things I will…

1) Discharging cured patients- nothing more satisfying in the world,
full stop end of line, paragraph and book. Watching a child who was close to
death running with his siblings around the clinic and then running into the
family in the market months later bright eyed and bushy tailed as if nothing
had happened has made any of the points listed above pale into the
background.

2) The walks to the clinics – with the recent dry weather and the use of
the car I've come to appreciate just how interesting the walking is. I've
been through villages that haven't changed greatly for hundreds of years,
and I've certainly been one of the first white faces ever to meet the people
who live there in their own homes. A truly once in a lifetime experience

3) The people I've worked with - Both local and international staff have
been truly inspirational, if I have given to them a tenth of what they have
given to me then I will be very happy.

4) Walks along the airstrip at sundown – Yes I know completely soppy,
but it is time for me, the only part of my day when I'm completely off duty,
it only takes about ten minutes but it really has kept me sane. And no place
does sunsets like Africa.

5) This! Writing this blog has been a wonderfully cathartic experience. But I'm
really not sure I'll have quite the same sort of material to write about in
the UK. I'm so pleased so many people from across the world have taken the
time to read it. If I have provided even a glimmer of what life is like in
this corner of the globe then it has been very much mission accomplished.

Would You Ask That Man To Stop Driving His Motorbike Through The Clinic?

I used this sentence as a title partly because it is a little eye catching
and partly because it forms part of a list I'm compiling entitled 'Things I'
ve said that seem perfectly normal here, but would seem crazy anywhere else'
Other notables include 'just come and hypnotise this chicken whilst I tie it
to the gas bottle', 'For how many days did you put the piece of cow bone in
the childs ear before coming to see us?' and 'It's really very simple, put
the gun down and THEN come into the clinic.'

So this week was a trip to a much-neglected clinic. So neglected in fact
that this was only my third visit in nine months. In many ways we have
failed them. There have been some fairly large extenuating circumstances,
the meningitis outbreak predominantly, but it still doesn't feel very good.
That the clinic is operating at all is miraculous however the lack of
supervision is evident here more than anywhere.

The drugs were being given out a little like party bags at the end of a
childrens party (i.e. everybody gets one) and the first morning we were
there we had to sack one of the staff for being drunk. It was a shame in
many ways as you are not only sacking an individual but also making life
much more difficult for his wife and children. But you can't really think
about that, after all drunk workers are not exactly good for patient safety.
Not a good start. It was to get worse.

In the afternoon I was sitting with the health worker in the consultation
room. In came an old woman with a basket. In the basket was a five-week old
baby wrapped in a blanket, I instinctively reached into the basket and
picked the baby up. The child was cold and dead. The grandmother said she
thought the child had died an hour or so ago but she had brought him in
anyway because she had heard we could bring people back to life. I think
this gives some indication of the general publics perception of what we can
do. I have to admit I was a little lost for words.

I stepped outside into the dazzling afternoon sun, it was still hot, but
dark clouds were gathering at the edge of the horizon. Dark clouds were soon
gathering in my head, my outreach buddy beckoned me over to the waiting
area. "Mate, I think this kid's got measles."

It's pretty difficult to describe how I felt; measles (thankfully now very
rare in the west) is still a huge problem here. One in every 250 cases is
fatal. If you score enough cases in a small village, (and 'enough' can be
less than twenty) you have to vaccinate.

I went through a bit of a cycle of thoughts. Firstly I tried to deny it "It
can't be, the rash isn't".this thought juddered to a halt as I found a
koplick spot (definitive proof it was measles) in the childs mouth. "Ok, ok
fine, perhaps it's an isolated case" I said glancing at the other children
around, and my eye being caught by one with puffy eyes and a very
distinctive rash. The faint sound of straws being clutched could be heard,
so I shut up.

As the week progressed we found progressively more and more cases. Most hadn
't come to the clinic at all and were merrily sitting at home. We went out
to a few of the surrounding villages and found more measles riddled infants
including one very sick child who hadn't been to the clinic and was in sight
of the health centres gate. The long and wordy public health books label
this sort of thing health seeking behaviour or (in intelligible English) why
sick people don't come to the clinics.

When I first arrived here I got the impression that people here were
actually very good at getting help if they were sick. People even seemed to
come when they weren't sick. The high numbers of patients pitching up with
nothing more lethal than a snotty nose seemed to support this theory.
However as time has gone on I've come to realise that actually we only
really scratch the surface.

If you were where I am now we could stand on the airstrip and look out at
the hundreds of huts and settlements across the flat savannah and I couldn't
tell you if the people living there were alive and well or all dying of
measles, meningitis or anything else.

So a week of measles investigation and general support ended with the
appointment of two new staff (always nice) and a vigorous game of football
on the airstrip. The plan was to return to base, pick up the stuff for
vaccination, come back out again and vaccinate. I was dreading it. The
logistical problems, keeping the vaccines cold, long days and nights and the
associated stress was not high on my wish list. Been there, seen that, very
much got the t-shirt.

On return to base we sat down and had a team meeting with all the staff from
the base. One of the nurses in the base said she had never done a
vaccination campaign and would love to come along too; objections were
raised about medical cover in the base. "You could always replace me???" I
offered, I tried (and probably failed) to make it sound like I was doing
them a favour, but in honesty, I think it was the other way around. So at
silly o'clock in the morning I watched as they bounced off along a dirt
track. I got to sit in clinic all morning and actually see some
patients.joyous!

I feel very much on the home stretch, a bit like a marathon runner rounding
the last corner, the end is in sight (two weekends left!) but there is still
work to do before I get there. In many ways I'm trying to pace out the last
few weeks. Increasingly I'm referring decisions about how the clinics are
running and focusing much more on the clinical stuff, which is the bit I
enjoy the most. The long and tedious human resource, logistical and program
planning problems aren't going to be solved in one visit and that's the most
I have to any of my outreach sites. Last week I said goodbye to two clinics
and their staff and this week I say goodbye to one of the two base sites.

At the first clinic I said my farewells to one of the staff said "I am very
happy, because you were there when there were many problems and things were
bad (the clinic was looted and destroyed and I was newly arrived for the
reopening) and now you have seen the clinic when it is good." I couldn't put
it more eloquently than that.

Novice to expert.

Assessment over we got into the business end of the week. Planes bringing
supplies arrived, cool boxes and syringes (in boxes!) lay everywhere. The
fridge generator grumbled and moaned over the extra work of trying to chill
more than two hundred ice packs.

Three weeks ago if you'd have asked me to organise a vaccination campaign I
would have found it about as easy as doing a newspaper crossword under
water, in Chinese. Now the only people who had ever done one before were the
driver and I. I was very much being looked to for all the answers, anyone
who knows me at all will testify that any answers on any question are often
beyond me at the best of times. The pressure was most defiantly on.

Thankfully the cavalry in the shape of a Dutch nurse arrived to help me out.
Very interestingly she had done my job here for nine months two years ago.
The more we talked the more we realised that we had been doing exactly the
same things during our time here. She had built a fence around one clinic. I
had rebuilt it. She had introduced anti natal care into the outreach sites.
I had reintroduced it. Sustainable development is a long way off I think.

Preparations made we got in the car at six thirty (or 'silly o'clock' as I
preferred to call it) and down the track went the vaccination travelling
circus.

The chief welcomed us and had arranged all the people in a queue!!!!
Obviously, coming from the UK I greeted the sight of people queuing with
utter delight and unconfined rapture, I nearly joined the end of it out of
habit. We rattled through eight hundred vaccines by lunchtime.

The way we set up a vaccination session is the same format wherever we go.
Two 'shooters' jab the people and the injections are prepared by the
imaginatively entitled (if not exactly succinct) 'meningitis vaccine
preparers', finally it's on to the tally sheet, to get a score at the end
and keep my boss happy. It's more like a factory production line than
healthcare. No time for chat and idling around, just keep them moving at all
costs. The vaccination team, when working well together run like they are
manning an artillery gun, not preventing meningitis, in this case our team
were superb.

The main problem here is that following a queue and 'move in one direction'
system (as we would know it) isn't understood by the population. We used
trees and string long lines of tape (almost identical to police cordon)
between them to try and encourage/force people to move in the right
direction, but many seemed happier to dive under the tape rather than
proceed to the tally sheet desk. I guess it's all about conditioning.

In the west since we learn to walk (and possibly before) we are used to
queuing up for things (post office, ticket booth, toilets etc etc) when you'
ve never had to queue up in that way or walk in one direction through a
series of points where you are required to do things it's not second nature.
For a while it was like herding cats! A few strategically place chiefs
helped a little.

We returned the second day for more of the same and pushed the numbers over
one thousand. Pats on the back all round.

It was onto a much bigger village and a bigger challenge the next day. In
order to get the maximum number of people possible we tied our vaccination
in with another NGO's food distribution day. This is (as the name perhaps
suggests) a designated day of the week when malnourished children and their
families get a weeks food ration. It's not exactly top-notch cuisine. In
fact it's dull and basic, but it keeps you alive.just.

People come from far and wide to the distribution, so we operated on the
'well whilst you're here, lets make sure you don't die of meningitis in the
meantime' principle. It worked well, too well. We had more than a thousand
people turn up. Crowd control became a real issue and in the end we had to
use tape on the ground and more chiefs to guide people. It wasn't wholly
successful with some chiefs seemingly unable to get people to move in the
right direction, and one, who was about as much use as an Easter egg in a
blast furnace.

By lunchtime we had vaccinated more than one and half thousand people. I had
had to abandon my job of supervising the vaccine preparers and plough into
vaccinating, opening a third line of people. This eased the pressure
slightly but people seem to be appearing from nowhere. My right arm had
performed the same action so many times repetitive strain injury almost set
in. I dreamt that night about having to throw a million darts in one hour;
otherwise crocodiles would eat me. I'm not sure the dream and the days
events were entirely unrelated, where the crocodile bit came from I'm not
sure, must be the anti-malarials.

History Repeating

'You don't need to do a meningitis assessment' the e-mail said, what a
relief, I could finally get out to do some outreach and sort out a
much-neglected clinic. Things were looking up. 'No, I think it's much better
if we just do a vaccination campaign'.

This sentence may just have well have been accompanied with the sound of a
horse, carriage and sherman tank being driven right across the plans I'd
spent a reasonable amount of time and effort sorting out. I've just
recovered from the last one, not again. Please, for the love of God no! My
head hit the keyboard meaning that the reply began 'dear
dfjrfdkvhemrfldkgj,/fdgkfqwjhkdkf;flbv,me#%. Which is probably a good thing.

The sun was just up, and still a very dark orange colour as we left. The
dirt track up to the first village was reasonably smooth, but with a few
vertebrae jangling ruts and divots. Along the way children ran from huts to
wave, the more brazen older ones made reasonable attempts to jump on the
back of the car. We managed to outrun them, but in some cases it was close

The plan for the day was to work out how we could vaccinate the three
villages that were home to our current meningitis riddled inpatients.

For those who think assessment needs to be complicated I would refer them to
our current method.

Step one - See which village the patients with meningitis come from

Step two - Visit the village

Step three - Vaccinate

In no way rocket science. But it seems to be working. We are already seeing
a real drop in cases in the first villages we vaccinated three weeks ago.
The vaccine takes two weeks to become fully protective. When I was a
slightly hard-up staff nurse I took a job giving out flu jabs to city
workers. This experience of vaccination has been altogether more challenging
but also a whole heap more rewarding.

The first village we visited already had not only a clinic but also (drum
roll) another NGO with expat staff. In many areas of the developing world
effective collaboration between different organisations is as likely as the
Pope converting to Buddhism, however in this case we actually get on very
well. I brought a few canned drinks, which helped.

Obviously there are parts of this NGO's programs and how they run things
that make me wince but I'm sure the same is true of them with us.

They don't have the sort of medical program we are able to offer, however
they have trained vaccinators coming out of their ears. Staffing issue
solved.

The chiefs in this location needed no convincing that vaccination was a good
idea. The eleven people who had been struck down with it in the month had
ensured that. They spent the next fifteen minutes criticising the NGO who
ran their clinic. All a little embarrassing, particularly since a few of
their representatives were present. I spent a long time finding a slowly
moving gecko ambling across the floor very interesting.

Anyway on to the next village, which was pretty much the first village in
microform. Easy to vaccinate, community very pleasant, no problem.

We then struck out for the third village. The road deteriorated with every
kilometre and finally evaporated into dense, low, scrubby undergrowth. The
Landover pitched and tipped down deep ditches and it was impossible not to
bang you head on the windows/seats/various other bits of the car, when I
emerged hours later I felt like I'd done a few rounds with an angry Mike
Tyson.

Finally we found a route through to the dried bed of a large river. This had
the advantage of being relatively smooth and easy to drive down it had one
major disadvantage in that it was impossible to see where we were. After
more than an hour of driving and frequent, 'lets try down here' detours we
finally arrived at the village.

A meeting with the village elders identified that they had indeed had cases,
though it was difficult to separate meningitis from other causes of death.
With the time it would take to walk to the nearest clinic of any
description, six hours, I find it pretty inconceivable that all the cases
made it to any form of health care.

There is absolutely no way of knowing how many people have had, or will have
meningitis. This village's inaccessibility makes it especially vulnerable
but it also acts as an awful catch twenty-two. The reason this village has
such a problem is it's inaccessibility, but it is this inaccessibility that
makes it, sadly almost impossible to vaccinate. The airstrip is too short to
land a plane, and the road is so poor it would break the car if we tried it
again. We also can't get there in less than three hours and the security
situation means we can't use another village as a staging post. Paranoia
about how cold we have to keep the vaccines has also reached new heights

I guess a year ago I would have thought that if you really wanted to
vaccinate an area it would be possible by some means. However just as this
area has no access to healthcare so healthcare has no access to it. We
returned back to base with the sun orange, but at the opposite horizon. A
vaccination campaign planned on the way back on the back of an envelope (I'd
forgotten my notepad). It was going to be a busy week.

The Beginning Of The End

It's three thirty in the afternoon and I'm lying on a blanket. The sun is
peaking through the leaves of the rustling tree above, book in one hand, and
Ray LaMontagne on the ipod. My return to first team action hasn't exactly
been frantic.

By the evening I'm back in clinic. A child with a fever and confusion, a
myriad of possibilities and the lab and microscopes are out of action until
we get some sun. Solar power the only option here. It will have to wait
until tomorrow, child admitted and settled. A man with a thorn deep in his
foot, an injection of local anaesthetic and a scalpel, tweezers and a few
sutures later and he's off grinning into the market. Sunday afternoon hasn't
been so leisurely in ages.

So I've sorted out my contract, which had been a little up in the air. This
whole adventure will meet its conclusion in a little over four weeks, I'll
have ten months on the clock by then. I haven't really thought about how I'm
going feel when it does all come to an end. A mixture of thoughts is a
certainty, sadness most obviously. What I do know is that I'm getting really
tired and it's time to get out before I become bitter and twisted or, more
importantly and more probable, start screwing things up!

So the plan this week (and it all changed an hour ago, so who knows whether
it will actually materialise) is to go and do some outbreak investigation in
a few villages, and then (and if this happens I might fall off my chair!)
possibly some outreach. I've been pushing really hard to get to one
particular outreach clinic, which is very much the forgotten child of the
four. It is consequently the weakest by a considerable distance. Not a huge
amount I'm going to do in a month but at least we can get things moving a
little before rainy season, which approaches with break neck speed.

I hope you all have good week. More as and when.

Fear Itself

F D Roosevelt was clearly a man way ahead of his time. In the late nineteen thirties he proclaimed that all we have to fear is fear itself (can’t see the current incumbent managing anything quite so profound). Sadly in the recent terrorist clamor this seems to have been rather lost.




In terms of your likelihood of dying at the hands of a terrorist it's one in 9.3 million. Which is roughly the same as being killed in an avalanche, no chance of that happening to me here, though a bit of snow would be most welcome! This is probably one of the few parts of the world not to have been altered by the events of September 11th and the US’s reaction to it.




However in its own way this country suffers from a similar paranoia. Recently there has been a spate of cattle raids, all pinned on one feared tribe, a few people have been killed. The local population has armed itself to the teeth in response. Recently the roof of a mud hut fell down (no one was hurt) but an old woman screamed. Someone nearby heard the screaming and presumed it was cattle raiding and opened fire. Someone else heard the screams and shooting and presumed the same and started shooting as well.



News spread round the village that there was fighting and the women and children fled into the surrounding countryside, having to be coaxed back during the course of the day. The chances of being killed by a cattle raider are very small indeed; none of my staff who I work with could name a single family member who had met their end this way. However this is inversely proportional to the panic they instill. The link between us in the west and terrorism is striking. Particularly when you look at the havoc malaria and other diseases wreak on a daily basis.




For malaria read heart diseases for cattle raiders read terrorism and the only conclusion one can draw is that we are all more than capable of irrational fear. It’s also interesting to note that in the west much is made of the media over exaggerating the menace of certain perceived threats to our health and safety (comets, bird flu, beef etc etc). Here however there isn’t any advertising and few people read newspapers and yet the problem prevails. Psychologists, sociologists and anthropologists book your tickets; your PhD subjects are just a few plane trips away.

A Much Needed Rest

We returned by car to the base site in the early evening. It was so strange being driven up the rutted dirty track to the base we normally walk down. A six hour walk became an hour long drive. Fortune had been on our side, this was about the only month we could have used a car, and used it had been, with great success. A mixture of insecurity and flooding meant that most of the year the villages are cut off to anything other than travel by foot.


The sky was a light orange colour as we crisscrossed the plains of this barren country and wound our way back to base. We drove past soldiers on drill, a water pump with maybe a hundred jerry cans lined up in a neat queue, herds of cattle and an old man playing with his grandson outside his house, the evening’s meal bubbling away in an old, battered pot on an open fire just behind them. Being in a car gives you a certain distance from life, anonymity, it was a strange way to view a country and it’s people I’ve come to appreciate hugely since last year.



A shower and an orange juice and I was fast asleep. Awoken just an hour later…”sorry mate there’s a gunshot, need you in theatre”.



Matthew was a young man who earlier that evening had been shot through the hand. Normally we would have just dressed it and organised for him to be flown off to a surgical centre for repair. In this case however the injury wasn’t so serious, just a lot of skin and muscle damage. So with a hefty dose of Ketamine we set about putting the bits of his hand back together. It took three hours. Admittedly a good fifteen minutes of this was spent hunting down a large grasshopper that was jumping round the room as if not constrained by the laws of gravity and evading all attempts to kill it.


Being a room full of blokes we suffered a complete failure to multi task and had to halt proceedings completely whilst we hunted for our errant foe. It was, however a bit too quick for us and finally escaped through a hole in the mosquito net covering the door. Back to work, hand repaired and patient left to sleep for the evening, wandering back to bed.


Two days later I was on the move again, but this time for a few days off at the missions’ base, the pace has been relentless it’s important to get your breaks when you can. The whole cliché of the work out hear being a marathon not a sprint is more true than I could ever have thought possible.


The clouds of rainy season have begun to gather again, bringing the climate to full circle. I've tried to explain to people who haven't been here long enough to experience the joys of the rains. The painful stagnation, the weeks without planes, trying to treat patients outside in driving rain. I've tried, I've failed.


It's rather like trying to explain this country and it's problems to all of you. I can give you a glimpse and hope that it makes sense but it's impossible to give you more than a vague feeling. Theres so much i'm unable to put into words.


As more and more of the people who I started with pack their bags and prepare to leave I find myself in the position of being an ‘old-hand’. It doesn’t seem very long ago that I was stepping into this madness for the first time, In some ways it doesn’t seem five minutes in other ways it seems like a lifetime.

Vaccination Situation

“How many?” The local authority leader sat back and scratched his beard. He thought for a moment. The room was silent apart from the rustle of papers. I sat on the plastic chair provided and took a swig of water. “How many days?” he said “five”, “seven thousand in five days?” He verbally regurgitated the figures, wrote something down, then stood up and wished us all the best.



Meeting over, we emerged into the glaring midday sun and into a whole heap of logistical problems. I’d promised the most senior official I’m ever likely to meet here that we would be vaccinating his community by the end of the week. Time was not really on our side. Every day brought a fresh batch of patients some with meningitis some with other things, a significant minority very sick indeed.



As walked back across town to the clinic my head was spinning. Could we really manage to vaccinate a series of villages with a group of people who had never given injections before? We were about to find out.



Whilst hurried preparations to bring in vaccines were made the satellite phone was never out of someone’s hand. The clinic and its staff continued on. We passed an unhappy milestone of seeing more patients than the base site, who have a permanent doctor and two nurses stationed there. This was like nothing I’ve ever experienced.



The best ways to describe how to care for vaccines to put them in the same bracket as vintage bottles of wine or champion race horses. Basically they have to be kept at a constant temperature and not roughed up in anyway. They become like an extra member of the team. Cosseted from the harsh environment by large industrial cool boxes, in the business we call it ‘cold chain management’ or how to keep vaccines at optimal temperature, always. The cool boxes were filled with vaccines and ice packs every morning, a miniature glass vial army arranged in row.



How do you run a refrigerator in a place with no electricity? You don’t. The vaccines were driven for an hour from the base site in the morning and brought back there in the evening. The word palaver doesn’t come close.



As we got up in the morning instead of “how are you?” it was more a case of “how are the vaccines? The level of care given to the cool boxes approached the level of some of our sicker patients, paranoia set in. The cool box temperature started to rise and worried faces abound whilst we tried to reorganise ice packs and move the cool boxes into the shade. If the vaccines were spoilt by the heat the whole thing would be for nothing. And this isn’t the sort of place where a fridge engineer can pop over and help out.



By this time, thankfully, the team had swelled to four. My outreach buddy had returned and there was extra medical help as well. However the main burden of the workload was given over to the guys we had just employed to vaccinate.



In essence we grabbed people off the street and told them that after a mornings training they would be the spearhead of a mass vaccination campaign. The simplest way for this to work was to give everyone only one job. The consequence of this is that you have an enormous number of staff to organise. Everyone from vaccine preparers to crowd controllers to child limb supervisors needed to be instructed. What on earth does a child limb supervisor do? I hear you ask.



The problem here is that it is difficult to get the mothers of children to hold them still. Culturally it seems it is not a done thing. In previous campaigns children have run away mid-injection, with syringe still dangling from buttock, like a porcupine. That wasn’t going to happen this time, not with a child limb supervisor in the team at any rate. This womans’ job was to grab errant children and restrict all unwanted movement. This female became the most feared woman to the villages under fives. In appearance she could best be described as robust.



After a day of training, our new staff were instructed to be ready for eight the next morning.



D-Day arrived. I sat on the airstrip watching the sun come up, cup of tea in hand, ipod on. The only five minutes of the day I got to myself, this day would define the whole campaign, if it went well the momentum would build. If it didn’t the campaign would be over before we had started. In the distance I could hear the megaphone of the local authorities informing the village that today was the day for meningitis immunisations.



Took a last swig of tea, headed over to one of the two vaccination sites. Already a long queue of people was standing around the tent. Seven exhausting hours later more than one thousand people had been vaccinated. Result! Much better than we had hoped for, the main takers were mothers and children.



The young men of the village didn’t seem to see the need. I guess when you carry an AK-47 wherever you go you don’t think something like meningitis will kill you. A twenty year old man tragically disproved that point later that evening.



For a week the pattern was the same and by the end 7758 people had been vaccinated. I had the ‘honour’ of giving the last injection. The child seemed not to even notice. They build them tough out here, they have to, it’s a very harsh place to try and grow up.

The Ides of March

In my previous incarnation as an accident and emergency nurse I came to
dread the month of March. For reasons no one has ever properly explained to
me the department saw huge rises in the number of patients in this month.
All sorts of possible explanations were given as to why this was, all I knew
was that, at times the place resembled Dante's inferno, on a particularly
bad day.

Anyway, no one had warned me that the inevitable switch from sensible
February to mad March could plunge the project to levels of chaos and
disorder not seen since some of my GCSE coursework.

Things had started reasonably well. I returned from a nice break and hung
out in the TB program for a while, which was very chilled out indeed. Later
that week there had been a plan to do some outreach and see the guys in one
of the clinics for some much needed training and support.

There is a famous military saying that no plan survives first contact with
the enemy. This plan didn't even have time to put its boots on.

The dust swirled around the plane as the propeller whirred. As I stood on
the airstrip, having just disembarked I pulled my hat over my face and
crouched down to try and shield myself from the biting sand. The propeller
stopped, the sand and grit did not. We had landed into the middle of a
sandstorm. It lasted only a few moments but everything was covered in a fine
film of grit.

We had received a letter from the health worker that he had had a huge
increase in the cases of meningitis in the clinic. Another clinic had
reported that people had started pitching up from a village half way between
the two. Four people had died already, and sadly that number was to
quadruple before the end on the fortnight.

With me was not my usual outreach buddy (away doing a similar assessment
somewhere else) but a nurse from Denmark, Anne, with loads of experience in
this kind of misadventure and, being Scandinavian, impeccable English.

We landed at around lunchtime and, after throwing the tents down, we headed
into the clinic. We didn't leave until just past midnight. Enough critically
ill people to fill an average western intensive care unit, and all requiring
just that level of care, had it been available. It wasn't, the nearest they
had was me and another nurse and a group of utterly exhausted clinic staff.

We ran out of space in the huts and had to get one of the guards to drive
wooden posts into the rock hard ground outside so that we would have
something to hang the IV drips on. At sunset I looked out across the clinic.
A few small fires were burning as caretakers tried to sort an evening meal
for the patients. It was surreally peaceful.

I fell into the tent and slept with clothes shoes still in situ and
stethoscope round my neck. To be woken a few times during the night to sort
out various drips and, sadly, to confirm that another family had lost one of
its members.

The next day we organised a meeting of the chiefs. Well, if I'm being
strictly accurate, we gate crashed one that was already going on. As we sat
under the tree they told us their people were dying, we asked them to show
us where.

So the next morning I found myself walking out to an outlying village with
not only a chief but also a bulging medical bag and absolutely no idea what
we would find. The chief pointed, with a long stick he carried, to a hut.
'Two children are very sick in there' he said.

It was dark inside the hut. Shadows moved around in the dim light as my eyes
struggled to readjust to the sudden change from the glaring brightness of
outside. As I looked down there was the wizened face of an old woman (the
grandmother) kneeling over the lifeless bodies of two children. The younger
was three, the older eight. Without any further examination it was clear
what had happened.. meningitis. We carried the children outside and placed
them under a tree. Both were contorted with heads thrust back, rigid and
feverish, they were gurgling very ominously. We administered strong
antibiotics and organised for the chief to take them to the clinic.

My heart was now racing, how many more would there be in this village?
Thankfully the answer was none. After a few more hours of walking round the
village we returned to the clinic. The drama of the day wasn't over however.

It was about ten o'clock that evening, I had just managed a few spoonfuls of
pasta when one of the clinic staff appeared at the gate. There is a very
sick baby you have to see. I walked/trudged over to the clinic. The child
had a nasty case of pneumonia so I set about sorting out some antibiotics.
As I was sitting in the pharmacy a few shots rang out, reasonably close.
This is a fairly frequent occurrence here, mainly a result of a very heavily
armed population.

As I waked across from the pharmacy to where the child was sitting a few
more shots. All seemed to be aimed skywards. Very quickly after that a lot
more shooting, and this was not going into the air. Perhaps thirty seconds
later what can best be described as bursts of very loud, very close, machine
gun fire pierced the cool night air. At this point I abandoned my 'how to
give your child antibiotics' chat and opted instead to lie on the ground and
crawl, very slowly, to the relative safety of one of the huts. Five minutes
doesn't seem a very long time, I can assure any reader when there are very
hot bits of metal fizzing over your head it seems like an eternity.

After leaving a healthy fifteen minutes from the last shot I emerged from
the hut and looked for Anne. Thankfully she was fine and had much the same
experience as me, spending a good half an hour lying on the floor of the
kitchen. We opted to stay put and not try and walk to the other clinic or
back to base, often the worst things to do in these situations is to move
around drawing attention to yourself.

In the morning it was as if nothing had happened. Apparently the bullets had
been expended in the quest for the meat of a hyena. I'm yet to be convinced.
Not a single shot heard for the rest of the week. Maybe they had used up
that weeks ration.

The next evening I did what any sane mid twenties bloke would do, and rung
my mother. 'Keep your head down' was her sound advice. Obviously working in
an area of conflict these things are occasionally going to happen. However
not one of us, here or in the west, can wake up in the morning and say we
will see the evening with an absolute certainty. I could be in places much
more dangerous and the crucial difference here is that I'm not a target; I
can't say that of the place I call home, London.

And what of the two children with meningitis we had found in the village?
After a week of convulsions, antibiotics, and crossed fingers both children
walked home. In terms of a justification for being here, no more reason
needed. Next blog.....Vaccination.

Happy Easter all

Real Politick

Currently there's a song doing the rounds on my Ipods 'on the go' list. The
opening line goes 'God please bring the rain, make it soon'. (Ryan Adams,
The Shadowlands, Love Is Hell Part 1 EP, for those who are interested!).
This always raises an ironic smile, rain is at least a month off and it is a
thermometer busting fifty-two degrees for a few hours most days. The ground
has lost all semblance of vegetation and so the wind carries sand and grit
in thick clouds across the clinic. If you happen to be outside as this hazy,
gritty veil descends the only thing you can do is put your head down and
wait for the cloud to pass as visibility drops to just about being able to
see your feet.

I've just had a short break in the outside world, which was great, if a
little odd. On the first afternoon, I plonked myself down in front of the
bastion of intellectual journalism Sky News. One of the stories I watched in
dumbstruck awe can be paraphrased as follows. Ricky Martin (the term 'Latin
pop sensation' was used more than once in two minutes) was recovering from
the loss of his personal mobile phone with (and this quote was so good I had
to write it down!) 'Personal numbers and addresses contained on it' however
brave Ricky still managed to put on a good concert in Sao Paulo. The
reporter then interviewed people leaving the concert and asked if they had
enjoyed it, to which they replied yes. Words fail. Thanks a bunch Rupert
Murdock. Any updates on whether the phone was ever recovered would be
greatly appreciated. This corner of Africa waits with baited breath… maybe
it's with Rhonda…

Anyway this week my outreach buddy has been off doing a meningitis
assessment and I've been hiding in the TB clinic trying to stay out of some
of the teams burgeoning issues with … er…each other!!! I really can't be
bothered to go into the whole thing, basically Babbage didn't slave away
inventing the computer only for me to use it to moan. A good friend of mine
who's been involved in this sort of caper before e-mailed to muse that even
' hundreds of miles away in a totally different world - you still have
office politics! Grrrrr'. You can't put a group of complete stangers in the
same place for months on end in what, at times, can be an immensely
stressful situation and not expect the odd problem.

I've adopted a Swiss approach of staying out of the way until the verbal
bullets
have stopped flying. Obviously it's not as straight forward as this, and
everyone seems to have an opinion and an oar poised to be stuck in!!! Anyway
luckily I'm not in the firing line and, as ever, I seem to be given my own
free reign to pretty much do what I want, which is lovely. I've also got a
list as long as an orang-utans arm of things to catch up on so I'm not
exactly idle.

Having said all that, far more challenging than any of this has been the
patients we have seen this week. Perhaps the saddest has been a woman who
attended with acute psychosis. The history is vague and there are hushed
whispers of possession by evil spirits and curses.

After she first became ill, and very agressive, the family, were unable to
deal with her safely and so did the only thing they thought would help, they
tied her to a tree for three days. Finally they brought her to us. 'They
said she tried to bite them' said one of the health workers as we tried to
investigate. I have to confess that if someone had tied me to a tree for a
few days I would view this as a reasonable course of action. This point
seemed to get a little lost.

She had kicked and struck out at anyone of her family who went near her. The
first thing we had to do was untie her hands, which were bound with thick,
chaffing, rope. She lay on the ground, with a terrified look in her eyes as
we approached her, very slowly. Rather like bomb disposal or going on
Celebrity Big Brother this, clearly, had the potential to go very wrong
indeed. Before we attempted this I must confess there was a syringe with a
hefty dose of Diazepam in my back pocket. Thankfully the most I got from
this poor woman, upon her release was a rather overly enthusiastic hug.

Sadly, the only way we can deal with this problem presently is anti
psychosis drugs and very heavy sedation, just so she doesn't hurt herself.
We are going to bring members of her church to speak to her this week and
see how it goes. This countries scars run so deep, I'm not sure a lifetimes
worth of counselling would even scratch the surface.

Otherwise I've got my TB team doing a teaching session for me on local
culture in return for half an hour on the side effects of TB drugs.

If you are a child the only side effect seems to be that they make you
insanely happy. The compound where the TB patients are is always teeming
with children, quite who they all belong to I'm not sure. Thankfully after a
fit of laughter most of them let out a rough, gurgling cough, thus
justifying their presence. I've taught most of them to pull faces, and blow
raspberries which has, obviously pleased their parents no-end. No one can
say I haven't left a legacy.

Match Of The Day

After the brief restbite of vaccination, I've spent end of this week cooped
up in an office tying up various loose ends. The monthly statistics , and
various contract wrangles have taken up days on end. I doubt if we will sort
out all the contracts by the time it is time to sign the new ones next year.
Selfishly I won't be here when that happens so I can very much pass the buck
and just concentrate on this years organisational disaster. Which, frankly,
is more than enough.

I think my essential problem is that there are too many 'Mary's' in this
country! Out of a staff of fifty five I have to supervise eleven are called
Mary! This country gives it's people a plethora of names after their first
name. All are similar sounding similarly spelt, rather like China (which I'm
told only has four variations of surname!) and the vast majority of them
begin with the letter N, Vowels pop up in perculiar places and the whole
notion of words being spelt like they sound is clearly alien here (the 'TH'
sound, sounding like 'si' anyone?)

The contracts of two Marys were mixed up and sent to the wrong clinics,
signed by both of them and sent back, so now I've got to go through the
whole process all over again. Included the dreaded social insurance form. If
I'd really appreciated how time consuming it would be to get the contracts
for the Marys (and the others) sorted I would have probably filed them in
the bin at the beginning. That a country lacking in even the most basic
healthcare infrastructure can construct such an impressive assault course of
bureaucracy is baffling.

I'm never going to call any future offspring Mary out of protest. If all the
currently employed Mary's all did different types of jobs we would have
enough of them to staff an entire clinic with people called Mary. Or, to put
things another way, and the link is a little tenuous I grant you, we have
enough Mary's to make a football team. Which neatly leads me on to my
Saturday afternoon activity

Some of you, I'm guessing, may have watched a game of football this weekend.
The particularly active ones might even have kicked a football round the
park or played in a more organised game. I spent the afternoon playing a
game of football like one I've never played before.

The teams were mainly members of our staff. All in their mid twenties, like
me, all very keen on football, like me, all able to play high tempo football
in forty degree temperatures with apparent ease and there the similarity
ends!

The match was conducted on the airstrip, the only area of flat land without
scrubby bushes. The ball was a nice new one we had flown in. The goals were
hastily erected sticks. The referee dispensed with the more usual black polo
shirt and shorts and instead went with a long flowing white robe and a
cowboy hat.

Most of the players opted to play minus shoes but from the power with which
they hit the ball and the boldness of the tackles you would never have
guessed. I had told myself that getting injured doing this would be a
particularly stupid thing to do, so any tackle that looked a bit dicey I
stayed clear of, making look like a complete wimp.

In their ultimate wisdom, my team decided that out on the right wing was the
place for me. If I'm honest I think it is because they wanted me out of the
way. When David Beckham plays on the right wing he does so with gusto
running for miles on end up and down the line sending in cross after cross
with laser guided accuracy. When I play on the right wing I flail around in
the manner of a lost lunatic. If the ball ever heads my way I try to do
something productive but inevitably end up apologising to my team as the
ball sails out of their reach. Very much a squad player me.

The game was interrupted by several pitch invasions, firstly by a group of
moping donkeys and then by a group of cows. One of whom decided to sit down
in the middle of the pitch and had to be encouraged to continue on its lazy
stroll.

The game was also halted for the six thirty bugle and ceremonial lowering of
the national flag, this disrupted my teams brightest portion of play for
about half an hour. I wondered what Alex Ferguson might have said had he
been in charge 'Well Garth, I thought we had the upper hand until the
flipping bugle and those donkeys!' Maybe something for FIFA to consider,
nothing is beyond them.

A tough, equally fought contest that defined the term 'a blood and guts tie'
. In fact with some of the tackles flying in it is a wonder that some of
those same blood and guts were not scattered across the pitch.

It finished two-two, and in the best footballing traditions both sides felt
hard done by.

Getting your jab in first

Trying to explain to someone who has never seen a boxing match, who Henry
Cooper is didn't work that well. Explaining that, now, his main role is to
try and convince the UK population to be vaccinated against a deadly disease
(flu) met with equal bemusement - 'the government has to tell people
vaccination is a good idea? I thought you all went to school?' Fair point.

We then got onto a conversation about boxing. For someone who has only ever
seen fighting that ends with a burial this seemed about as alien as people
not wanting to be vaccinated.

'Why do they wear gloves?'

'So it doesn't hurt'

'But you just said that people can get brain damaged'

'yes they can..er..it's a strange sort of sport'

'hmmmmm'.

Being a white face seems to mean you have to have all the answers to
everything all of the time.

Those, in the UK who see vaccination, as some sort of optional extra should
come to a place like this and see the children here who are maimed and
killed by childhood illnesses such as (to pluck three at random!) measles,
mumps and rubella. The more people you vaccinate the less likely the others
are of getting sick, so everyone is a winner.

Anyway I'm getting off the point. After much logistical huffing and puffing
we finally got the equipment in place to vaccinate the clinic staff against
meningitis. Just getting to this stage was a difficult enough from an
explanation point of view 'you want to give us an injection, but we're not
sick!' 'Why will you vaccinate us, but not our children' the simple answer
is that we haven't enough vaccine, but that's not a very satisfactory answer
for anyone.

It also involved one of those GCSE maths questions that I loathed with a
passion at school. Marcus has to vaccinate 137 staff each vial will
vaccinate 50 staff. How many vials will he need? Obviously it's not exactly
degree level arithmetic, I still managed to press the wrong button on the
keyboard and went quite far down the line towards ordering four vials, until
someone pointed it out!

Anyway the appointed day arrived and I sat with a translator and a large box
of syringes under a large tree and zapped the vast majority of the staff.
Very refreshingly when one of my outreach staff was late the rest of them
feigned immense pain in their upper arms, as if I'd injected them with a
pitchfork!! Glad to see stupid schoolboy humour crosses seas and deserts
with such apparent ease.

At least we have prevented a few people from dying of a preventable disease,
but in the grand scheme we really haven't scratched the surface, or as Henry
Cooper might put it, our guard is very much down.

What Happened Next.

I seem to remember finishing the last blog with the words 'I'll write more
tomorrow'. I didn't..here's why.

The computer made a satisfied 'ping' noise as my last e-mail dispatched
itself into cyber space. A second later the satellite phone next to me
sprung into life.

"Ah, good, you're still up" (the boss, in the other base site)

"Yep, was just about to knock off to bed actually."

"Well don't, you are going to be on a plane tomorrow morning. there's a
report of cholera in one of your outreach sites on this side"

"S**t"

"And lots of it.apparently"

No sleep, spent hours packing. Kept myself alive on coffee for two days.

The previous week had been a really hectic and the most physically demanding
of my time here.

The much vaulted nutritional assessment had begun. The plane had dropped off
a senior nutritionist, to a group of very sceptical medics, in fact to be
honest we must have seemed like a group of grumpy teenagers. I think we all
expected to be told off. She had arrived to assess the childrens feeding
program and make suggestions on how to improve it.

If I'm honest I'd been dreading it. I thought she would surgically attached
to her desk who'd never so much cast eyes on a malnourished child, let alone
tried to feed one. Thankfully I was pleasantly surprised. Ellen was a
veteran of various projects and certainly no stranger to the hardships
experienced here. Though she did say it was the most basic place she'd ever
been, which I take as a sort of bizarre badge of honour.

The plan we hatched was to try and do two short visits to two outreach sites
and do a brief nutrition survey in each. It's worth giving a quick overview
of the nutritional state of this nation.

In short there just aren't fat people here. Malnourishment as we would see
it is so insipid here as to be a meaningless term. The mothers here never
attend the clinic because their children are under weight. They present
their children with the problems that are associated with it, such as
opportunistic infections.

It is hard, as a westerner, to deal with this. In the beginning I used to
internally fume (thankfully I never voiced these views!) with the parents
'How could you not see your child was thin, he's just over half the weight
he should be???!!!' But I've come to discover it is simply a matter of
perception. They haven't seen what a fat baby looks like so how would they
know what was healthy. I could leave this office and within five minutes
find a handful of children suffering from some level of malnourishment,
although it's dark now so people might ask a few questions, and I might be
arrested!

We headed out in the early morning sun for the five-hour walk to the first
outreach site. Luckily the weather was reasonable and only hit the mid
thirties, amazing what a boy from rainy Britain will put up with. Moses was
there to greet us and eagerly pointed out all the houses of the people who
he thought were hiding underweight children, armed with this information we
retired to our tents to sort out a plan of attack

We left early the next morning with the thermometer soaring into the high
forties. The first few houses yielded no children under five (our target
group). As we ducked a head into a large hut nearby we seemed to interrupt a
local conference of the villages under fives and busily set about taking
measurements. Both mothers and children greeted this with amused
bewilderment. Some wanted to be measured twice!

Onto the next cluster of huts with a notebook bulging with data.

"Hello, we are doing a survey on malnourishment, do you have any children
here" I said.

'Ahh, good' Said the nearly toothless old woman making her lunch outside "I
'm so pleased you've (she actually used the local word for foreigner) come."

"Good, so er.. Do you have any children under five?"

'No, but in that tree over there is a really big snake with eyes that shine
like torches at night, you can kill it for me"

"Er. that's not really what we've come here for"

The conversation was abruptly halted, just as it was getting interesting; by
the translator who said that he thought the woman had 'confusion from God'.
I may be from the same place as St George but reptile slaying wasn't in the
job description. We left the woman and her ferocious snake to fight it out
amongst themselves. The results of the malnourishment indicate that at
present things are reasonable but unlikely to get better and, as the wait
for rains continues, likely to become more acute, one to watch.

The second outreach site, run by the easy-going, James was, as ever, a joy.
The staff are the brightest of all four sites I see, they are eager to take
on new skills and learning. Sadly, the community they serve doesn't match
this commitment. We have been asking for help in constructing some new
buildings since late October, and still they remain unfinished. The whole
process should take a week or two at the most. It seems (to quote a
favourite phrase of my brothers) they can't be arsed.

So we decided to play hardball and call a chiefs meeting. Items on the
agenda included some health education and a chat about malnourishment as
well as the participation issue.

I wandered through the market at lunchtime and was greeted by an alarmingly
drunk man who shook my hand more, out of a need for physical support, as
much as an expression of greeting. This man was (I discovered half an hour
later at the meeting) the head chief. The meeting revolved around us trying
to reason with a man who was barely able to sit on his chair. Some of the
sub chiefs seemed interested but others just seemed to be following their
leader into alcoholic oblivion, including the head of the prison service,
and no, I've no idea why he turned up either, maybe he brought the booze!

So, in conclusion, a bit of a waste of time. I did a least get the pleasure
of watching the chief trip over and fall down a small hole just outside the
clinic as he left the clinic. With leadership like that who needs enemies.

It was soon back to the base and the late night 'cholera' phone call.

We had come back early to the base to help deal with a small outbreak there,
we were intending to stay a week. This phone call changed plans
dramatically.

In the bases there is a permanent doctor and nurse presence. Monitoring of
disease is much more rapid. The outreach clinics are run by national staff
(with support from our sporadic visits) and the only communication is a note
sent by runner. In truth an epidemic like cholera or meningitis could fester
for weeks and no one would know.

This outreach site had reported on Monday night they had a possible cholera
death and was treating a patient with suspected meningitis. We got there, by
plane, early on Tuesday morning.

First problem was to assess the patient (a fifteen year old boy) in the
clinic, with possible meningitis. I have never been so proud of the staff in
any clinic I work with. The symptoms were a little vague and it was not, a
classic set of symptoms. No blood tests, no lumbar puncture just a set of
vague signs. We would not expect that level of judgement of anyone in the
UK. But they done what it said in the book and given the patient Ceftriaxone
(the meningitis antibiotic), without any hesitation. In doing so they had
undoubtedly saved his life.

The next day we left to go and see the patients' family (a check they weren'
t all struck down with it too) Thankfully it seems an isolated case. We
moved onto the house of the man who had possibly died of cholera. He lived
in a little hut, tucked off the road, surrounded by red acacia trees. He was
a strong man; twenty-five years old (the same age as me) he had a wife and
children. A week ago he had complained of feeling unwell, had begun to vomit
and had loose stools a few times (Crucially not the right sort or volume for
cholera). After a day of this he was taken to the clinic and they had tried
to treat him with what they could and refer him to the base. He never made
it.

We sat under a tree with his wife, children, mother, father and
grandparents. As they told us about his final days the grief and pain which
they felt became obvious. They answered some very painful, difficult
questions with as much information as they could. The dignity with which
they spoke about him was humbling. I had worried there would be an element
of 'well, where on earth were you lot when we needed you?' but they simply
accepted it as part of some grand plan. I can't even pretend to say I would
have managed to view it that was so soon after the event. Profoundly moving.

In short, I haven't got a clue what killed him. But I'm as sure as I can be
it wasn't cholera. We returned to the clinic and a meeting with the village
elders with the news. A proclamation like this is a heavy burden of
responsibility.

To tell a towns elders that you don't think they have a cholera outbreak is
a very big call. Particularly a county town the size of this one. It's not
the sort of thing you can get wrong. You couch the sentiment in 'with the
information we have at the moment' and 'obviously, without seeing the
patient and doing tests we can't be sure'. But no one ever remembers those
bits. We are saying the village doesn't have cholera at the moment. Full
stop. Reputation and trust very much on the line, not an easy day.

That evening we saw our second meningitis patient. Thankfully, if all goes
as it is going at present he will recover. As we flew out from the dusty
airstrip, and back to base. I left a place will still much uncertainty. Will
the meningitis cases continue to rise? Will cholera stay away? (With the
water situation in the village the realist inside me says it's unlikely). We
shall see.

So I'm back in the base now, can of coke in hand, after a hectic few weeks
it's nice to have a few days to chill and do some paper work, and I never
thought I'd say that!

These Boots Are Made For Walking

And thats just what they'll do. And one of these days these boots are going
to walk...er...somewhere near a place that has power and a computer!?????!!!

I've not been near a computer in weeks and when I have the e-mail has been
so slow I considered carrier pigeon. Hence it's been such a long time since
I've written, sorry one and all. I hope some of you are still checking this
site, more to follow promise.

"You must be kidding!"

"No way, rubbish, I've never heard that before"

"No, no he might be right"

"Right that's it we are going to buy one tomorrow and see if it works"

Barely twenty-four hours after this conversation I found myself knelt on the
ground drawing a straight line in the sand. Resting at the start of my line
was a beak. The beak was attached to a chicken. And it was hypnotised.

We had arrived at this particular outreach site with not just the usual
suspects. (i.e. me and another poor soul) but also a medical co-ordinator
and a logistician. A huge team by outreach standards.

In honesty, and for reasons so oft repeated it's boring, we had not visited
this clinic (nor the clinic we moved on to) often enough. It wasn't that
they were doing badly but they were (as an NHS manager might put it) 'in
need of input'. More of this later, back to the chicken.

Sitting round a camp fire (containing large amounts of out rubbish that I'd
forgotten to burn the last time!! Whoops!) That night we got into a
discussion about hypnotism and naturally (work with me here) the
conversation moved on to whether it was possible to place animals under
hypnosis. One of our number suggested the method and the following night we
performed a controlled test, of sorts. And it works!!!! For those of you
with access to chicken, and perhaps it's best if you chose a reasonably
docile one, please feel free to conduct a similar experiment along the
following lines.

Take one chicken, lie it on the ground and point it's head to the floor. If
another person slowly draws a line in the sand with their finger in a line
from the beak, about two feet, outwards, the chicken should remain
motionless…indefinitely!!!

Pushing back the knowledge of an outreach team one night, awesome casserole
the next. We had brought the chicken to late to eat that night and were not
overly thrilled with the prospect of the thing squawking for hours. So this
did have a practical purpose too. Not a peep, all night.

Things were going relatively well clinic wise. The contracts were signed
with only one amusing question.

Marcus: So your contracted hours are 40

Staff Member: What …… a day????

Marcus: Err… no…(Completely thrown by this question) a month. …Err. I mean
week. Sorry did you just say a day?

This story would be slightly less worrying had this question not come from
the man in charge of counting the stock!!!

It had been decided to make this town the new county town, what was wrong
with the last one hasn't been properly explained to me. Anyway, the town was
awash with people building and busying themselves. Hundreds of young men
have moved in to work for the various offices of local government, making
the town almost completely young and male. I'm not sure the long-standing
inhabitants quite know what has hit them.

Within a week we had fixed a fence and been able to do some very rudimentary
training with the staff. Often the process involves high amounts of damage
limitation. It's almost about making sure the staff do no harm and then
getting them to do things well. Having said that people like the wound
dresser continue to improve.

Another success was the lady we employ to give the first dose of the
medicine to the children. In many cases (unlike the UK where children are
brought up on a diet of antibiotics) this is the first time the children
will have taken any type of medicine and the mothers are understandably
clueless about the best method of administration.

On previous visits I'd observed out medicine lady using a combination of
face grabbing and overwhelming force. Rather like a patient with aggressive
psychosis the children would be pinned to the ground by an army of mothers
and bystanders. Arms and legs flailing, medicine spat and crying as if limbs
were being pulled off. The whole spectacle resembled a horror film.

This led to some very big questions from my bosses about why it was that our
clinics were using double the number of drugs they should have been. With
the number of children this lady made vomit I'm surprised the number was so
low!

Changing the behaviour has been long and laborious. Starting with, O.K. lets
sit the child up and THEN grab his face to finally, on this visit, lets get
the child to take it off a spoon calmly. I'm sure on occasion the urge to do
things the old way is still strong, and I've no idea what they do when we
are not there. But at least I've tried!

Onto the next clinic. This very calm and tranquil little village had had the
impressive joy of having a borehole and water pump fitted the month before.
This great news had turned very sour as the pump had spluttered water for a
whole day and then produced nothing more impressive than sand and sludge.

A team of engineers were on site when we arrived, swelling our numbers to
seven. Sadly the pump needed a very specific part, and had probably been dug
in the wrong place anyway… so the wait for clean water in this area goes on…

A very very very hot walk in six hours of baking sun back to base. The
temperature was fifty degrees for two hours of the walk. It was also across
open country so shade was limited indeed. All not much fun. Walked into base
with more than a passing resemblance to a raisin.

A quick shower and a beer and then on a flight to the next outreach site.
But more of that in a few days.

On The Road Again

So another week another clinic, I'm getting some idea of what it is like for
a rock-star to be on tour, minus even the merest whiff of luxury. It seems
like every night I find myself in a different clinic. I exaggerate slightly
but not much. So this week I returned to the first outreach clinic I'd
visited. As any smarmy estate agent (and, though I've never met a non smarmy
estate agent, I presume them too!) will tell you it's all about location,
location and location.

The clinic sits on an artery road between two major towns and provides a
useful stopping point for people walking between the two. The fact that it
has, not only a water pump, but also a fabulous clinic just gives it greater
added value. This means there is an awful lot of traffic that just visits
the clinic for one day, making things like, (heaven forbid!) the review of a
patient the following week, impossible.

The heat on the road up to the clinic was searing. For various reasons we
left late and the sun was already racing upwards into the sky. It's a hard
sun here, the heat and power from it is unremitting. Shade can offer some
comfort but really, there is absolutely no escape. Whilst the walking is
easier in terms of zero water under foot, the heat makes it exhausting.
After a while it feels like your destination is no nearer and you've spent
the last hour on a treadmill. Hamsters stuck in wheels, I can completely
sympathise! Half my rucksacks weight is taken up with drinking water. It's
like being locked in a kiln.

The first night we were there we had a lot of rubbish to burn. I emptied the
various tins and papers into a big pit and dropped in a few matches. The
rubbish hole was just outside the fence (that was still standing following a
struggle to construct it the last time that can best be described as
colossal!), so I left it to burn.

About half an hour later there was an ear splitting bang from the area where
the fire was. Just as I had had time to check all four limbs were still
attached, another explosion, coming again from the direction of the rubbish
fire. This second explosion blew a large crater in the side of the hole and
scattered bits of the fire over a large area, part of a sardines tin landed
at my feet.

People from the clinic and nearby houses came to see what had happened. We
swiftly put the fire out, with copious amounts of water. It hissed and
steamed for hours. Everyone went back to bed none the wiser.

The following day I raked over the remains with a stick. In the bottom of
the hole were two empty bullet casings. Why someone had decided that a
rubbish fire hole was a sensible place to put live bullets baffles me,
thanks to me they weren't live any more!

Other than trying to avoid starting another war the main point of this visit
was to sort out the new 2007 contracts. This job was made much easier by the
fact that everyone got a whopping pay rise. Unfortunately the process
involved taking a few basic details from each member of staff….

Name- well most got that bit right, though sometimes the spelling was
different depending on what form was being written.

Village- again, not exactly straightforward, because here it is pretty
difficult to determine where one village begins and another one ends.

Date of Birth- No one had any idea what their date of birth was. The tax
form demands a date of birth.

So what do you do when you have a crucial form to fill in and a piece of
crucial data unavailable? You make it up. So come with me, dear reader, as I
show you how to both construct an entirely fictitious birthday and thereby
commit multiple fraud.

Marcus: So, do you know what was the date of your birth?

Staff Member: No, Not sure

Marcus: OK what year where you married?

Staff Member: 1986 or 1989, I can't remember (Which reminds me of that joke,
how do you remember your wedding anniversary? Forget it once! Clearly not
the case here)

Marcus: 1986 ok? Right let's say you were twenty then so that makes your
birth year 1966, sounds reasonable?

Staff Member: Yep

Marcus: Any idea what month you were born in?

Staff Member: Nope.

Marcus: No Worries. Pick a number between one and twelve

Staff Member: Erm… Seven?

Marcus: Right, July it is! OK nearly done, any idea what date you were born?

Staff member: No.

Marcus: Not a problem. How many cooking pots do you have at home?

Staff member: Four

Form: Date of Birth

Marcus: 4/7/1966

Voila! Born on the forth of July! This process has been repeated more than
thirty times so far and we aren't even half way. Painful.

Medically, we drained 65mls of fluid off an old blokes knee, (which was very
satisfying indeed.) and the workers in the clinic brought yet another child
with cerebral malaria back from the dead. Rather embarrassingly we turned up
just as the child was turning the corner and so got all the plaudits for it'
s remarkable improvement. Completely undeserved credit is no credit at all.

The walk back was uneventful apart from three very large trucks, the first
cars I've seen in six weeks, thundering down the track. All were laden with
soldiers. The lead truck stopped and the portly commander got out and
introduced himself. My heart was pumping like a train at this point. Trying
to remember what I'd been told to say to highflying generals/army commanders
in my briefing.

It's a bit like talking to the Queen in terms of etiquette. I settled with
just calling everybody 'Sir'. As he approached I looked at the back of
truck, which was stuffed to the gills with soldiers, all young, all armed to
the teeth.

I cursed the fact I hadn't any cigarettes to offer as a bargaining chip.
Being a non-smoker can seriously endanger your life, they should warn us.
Thankfully he was very jovial and offered us a lift. Whilst it would have
turned an hours walk into a few moments drive and was thus very tempting, it
's not quite the done thing and would have got me a flight home much sooner
than anticipated.

Pleasantries exchanged they drove off, the black faces and white teeth of
the soldiers in the back of the truck disappearing into a cloud of dust and
chocking acrid fumes from the badly tuned, gurgling engine.

Tomorrow we are off again, as the outreach travelling circus rolls onto its
next location. So more in a couple of weeks, when we are back in a land of
electricity and e-mails.

Forward and on

With a head still awash with numbers I got up early to try and finish the
statistical report. After a nights sleep it made even less sense and the
notes I had made seemed to be written in a language not of this earth. Never
mind, report dispatched, just have to wait for the feedback on it….gulp!

As is usual for the arrival of the plane, my preparedness was not exactly
that of military precision. Stuffing what clean clothes I had into a small
bag and grabbing a few biros and rushing towards the airstrip I arrived at
the gate and spun on my heal remembering I'd forgotten my stethoscope, I did
this little dance a few times as various other things came to mind that I'd
also left in my hut. The engines were running (A pilots way of telling you
to get yourself into the flippin plane... pronto!!!) by the time I clambered
aboard.

The flight to the outreach site was, if I'm honest, embarrassingly short. It
took just over five minutes to cover a distance that takes as many hours to
walk. The same pilot who flew us last time (and got lost, stop sniggering at
the back there!!) Flew us again and this time there was no mistake, the
airstrip was soon teaming with people who ran to observe this strange lump
of aluminium that had interrupted their morning. This was only the second
plane to land there in two years.

Anyway once landed things were pretty much as we had left them in December.
Everything was running well, various different problems had cropped up. A
few of these later. The BIG difference was the people who I'd got to come on
outreach with me. After a lot of pleading with the boss I'd scored a major
success. We had not only my new outreach buddy but also (da da
daaaaaaaaahhhh!) a Logistician. This I think was because, frankly, when it
comes to organising, things like logistics it's better to get
a ….erm…logistician.

Anyway with the various logistical bucks successfully passed we endeavoured
to try and sort out the medical side of the whole business. Moses (for it
was he again) was doing sterling work. Despite the fact that we hadn't
really worked with him since his arrival, he'd even managed to organise a
half decent off duty rota for the staff (BIG step forward)

The feeding program being offered to the populations' malnourished children
was disaster on every conceivable level. Sadly this wasn't his fault, and
therefore nothing we could easily correct. People seem unwilling or unable
to return for the repeat visits required in order to cure the malnutrition.
With a walk of six hours in temperatures that are in the low forties Celsius
it's not hard to understand why.

Medically the major problem was diarrhoea, no water pump still, it keeps
being promised by another agency…. never happens…out of my hands…tired of
being angry about it… Like so many before me I'm just a bit resigned about
the whole affair now. It's just so depressing,

The water level is lower and scarcer now so the quality has dipped still
further, the dirt is more concerntrated now. I'm not sure how this is
possible, but it is. A thick layer of brown slime sits at the bottom of any
large water container when you empty it. That's all I can say without
screaming!

One morning I was called to see a little girl with a piece of cow bone stuck
in her ear, another unbridled success for our friends in the traditional
healing fraternity. With a pair of tweezers and a lot of tugging I managed
to get it out, but not before causing significant pain and a bit of
bleeding. Hopefully incidents like that will get the message across.

It seems a bit weird that these trips become mundane but it's funny also
what you get used to. A new outreach partner has reminded me how odd this
all is compared to healthcare in the western world. But the numbers (for
this is what really matters I suppose) are better than ever and we seem to
be saving more lives than ever. I cannot describe what an immense
satisfaction that is.

We left a few days later with the majority of the staff for a large party in
the base site. There were speeches under the tree and the staff killed a cow
(and frankly I'm not sure the Iraqi government could have killed anything in
a much more gruesome way!!) and there was signing and dancing long into the
night, I have to admit I was so tired from the walk back that I sloped off
to bed at a conservative 11.45pm. A wonderful evening.

So the plan for this week is a wander off to another outreach site with
large numbers of soldiers and large problems. Will let you all know how that
goes!

Lies, dammed lies and statistics

It is possible to prove anything, they say, with statistics. Who 'they' are
has never been explained to me. Personally, the whole notion of statistics
falls into the 'spirit crushingly dull' tray of my brain. I even find myself
reading the subject bars of e-mails and the mere mention of the word
'statistics' or it's evil twin 'data collection' and it's straight in the
file marked, 'stuff to read when I'm old, unable to move, and barking mad'.

Yes, yes yes I know it's very important to know what is going on,
particularly in clinics where we are not present all of the time, this doesn
't stop it being about as interesting as creosote.

It's the one part of this job I loathe. Every month four members of staff,
one from each clinic, skip merrily through the sand and grit (that until
recently was a swamp!) with books full of numbers to one of the two base
sites. I then have to take the numbers and try and make sense of them. There
are a few problems with this.

Firstly, counting, as has be proved ad-nausem is not a strong point here. I
once made the mistake of trying to explain the concept of percentages.
Frankly I could have been reading a washing machine manual, backwards in
Serbo-Croatian for all the good it did.

Secondly, this is not the sort of environment that lends itself to intricate
and detailed compilation data collection. The fundamental problem is that
the clinics staff are not able to compile large amounts of information in a
monthly report and do the jobs they are supposed to be doing at the same
time. We just about manage the big three, malaria, pneumonia and diarrhoea,
but get into the finer detail and the whole thing comes down like a house of
numerical cards. The raw data provided is erratic. For some months I will
know how many pregnant women pitched up, for other months I won't. This
makes trying to identify patterns hopeless. Conversations with my bosses run
along the lines of;

Marcus: We had a large number of malaria cases in November.

Boss: Really? What about December?

Marcus: Erm…… (Starts to find floor very interesting, makes shape in sand
with shoe, avoids eye contact, or speech. Exits stage right.)

I have been sitting here all afternoon (yes I know, on a SUNDAY!) trying to
do the kind of mathematical gymnastics that would have had Archimedes
wondering if there wasn't some other topic to philosophise about. It's not
much improved after six hours of work. But at least the Excel columns are
now in different colours!!!! The guys who cracked the Enigma code are the
only beings on earth who can truly understand my pain!!!!!

Thankfully in just over twenty-four hours we are flying to an outreach site
to do some fun stuff. My brain may have stopped dribbling out of my ears by
then!

BREAKING NEWS. Just got an e-mail from my medical boss. There is a
nutritionist coming next month to assess our feeding program in the
outreach. Despite much effort our feeding program is an unmitigated disaster
on every conceivable level. I'm in so much trouble!!!!!!!

In the bleak mid winter.

It is winter here. I'm not exactly reaching for the bobble hat, gloves and
Bovril. Not much of a winter season by all accounts, it is still hitting the
mid thirties every lunchtime, but the early mornings and evenings are more
chilly, I'm sitting here in a long-sleeved top!! And it hasn't rained at all
since I arrived back. I know that's nothing to those of you looking out on a
snowy blizzard, but it's a big deal here in the desert.

No outreach this week, I've tried to operate them by remote control and
failed miserably. I've dispatched various letters with various questions and
received letters with various answers, which would be fine, except they aren
't answers to the questions to the ones I've asked!!!

First task of the week - brief my new outreach buddy, another UK nurse who
is as new to this game as I was not so long ago. She bounced in from the
other base, with a whole load of other new people. The number of expats has,
instantly, swelled hugely. The majority of them are from the UK. This has
had the unexpected bonus of meaning the office computer's spell check has
now been permanently switched to English (U.K.). Proof of a change in the
balance of power if ever there was one.

The reason for the coming of the proverbial cavalry has been the massive
increase in workload and having them here has (rather typically) coincided
with a significant downturn in the number of patients, leading to our new
arrivals all wondering what all the fuss was about. I was trying to explain
that before Christmas, vast areas of the clinic grounds were covered by
people sleeping on the floor, now they are as God intended. Empty. I think
they tried really hard to believe me. They will see when it all picks up
again!!! I'm staring to sound like one of those awful people who rattle on
about how it wasn't like this in their day!!!! Must make efforts to
stop......quickly!

Anyway my new outreach colleague seems very keen and eager so that is a big
improvement on the last two. We hope to head to our first clinic as early as
next week.

I've found myself doing briefings rather than listening to them, which is
VERY peculiar. It seems only yesterday I was asking the sort of questions I'
m now answering. I'm fielding enquiries about everything from security to
the rates of malaria in expectant mothers without batting an eyelid!

Every day here provides me with a new challenge, and I can't say that about
any job I've had before. This week included the usual mix of triumph and
tragedy. The child with convulsions (mentioned in the last entry) recovered,
against all the odds, and is now running around with his siblings. I'm still
none the wiser as to what it was, but something we did, clearly, worked.

The usual collision between the traditional and the western method of
healing has continued unabated. We lost a month old baby who, inexplicably,
had been fed cows milk since birth and had a very serious infection of the
gut. As things became terminal I gave some morphine and encouraged the
mother to breast-feed for the first time. The child fed beautifully. I left
the hut, wishing the mother had just done that in the first place and not
listened to the ramblings of some village wise woman, all very frustrating.

On an up (because I don't like to end on a down note) I did a refresher
lesson with the staff on pneumonia and not only had they remembered what I
taught them but they had also gone away and read MORE. Some of the detailed
questions at the end rather threw me!!!! Off now to brush up on a few things
about digestion before I get caught out again tomorrow.

To the place I was before.

After a fantastic, and by all accounts, much needed break I'm back. But no
outreach just yet as having returned from a holiday I'm now covering others
time off. This at least allows me a couple of weeks to get slowly readjusted
back to life here. How quickly and easy it is to forget what a harsh and
unforgiving environment this is.

The flight back in was, thankfully, much less eventful than the flight out.
>From the air it is possible to see the transformation in the landscape.
Sandy yellow is the new green. The change is little short of remarkable.
This area gets more rainfall than south east England, it just happens to get
it in just under three months (July, August, and September.) The rest of the
year is arid and dry. I was looking at photographs of what things looked
like in August and it is like a different county. Our airstrip, that only a
few months ago was ankle deep in water, is now a long, thin sand pit.

The wind whips around the mud huts and the buildings. It carries sand and
dust in every corner and crevice imaginable. Every surface is covered in a
fine film of it. The air itself is warm and a little like having a softly
blowing hair dryer six inches from you… permanently. And this, my friends is
only the beginning. Soon it's going to get REALLY hot.

By the afternoon of my arrival it was back to work with a bump. Various
patients, various problems, all in need of sorting out. Tonight I've just
returned from dealing with a child who was having a nasty convulsion. The
fitting we have managed to stop, but as might be expected he remains deeply
unconscious. He has no fever and the malaria test is negative so I'm not
really sure why he is convulsing, there is a list as long of my arm of
possible causes. We have given everything and covered all the bases
possible, I've just had a bit of a chat with the mum and dad and they seem
quite clued up. The situation is, needless to say, dire. we will see how the
night goes, but it is not up to me anymore.

So a few weeks here and then, hopefully some outreach, with a new outreach
buddy who is currently in the other base, doing a similar job to me. There
is also a staff party to organise, so I won't be sitting around.

I hope you are all struggling back to work ok, for those who have e-mailed;
apologies for my hopelessness I will sit down and reply soon.